Texas Puts Brakes On Telemedicine; Teladoc Cries Foul

Telemedicine company sues Texas Medical Board over new rules.

On a recent trip to Chicago, Patti Broyles felt like she was looking at the world from the bottom of a fish bowl.

"This weather was really cold and rainy, and I had a lot of pressure in my sinus area," Broyles said.

Since she was nowhere near her primary care doctor in Dallas, she called Teladoc, the largest telemedicine provider in the U.S., for advice. Patients whose employers or insurers have deals with the Dallas-based company can call any time and be connected with a physician on duty within minutes.

Broyles said the doctor on the call gave her a prescription for antibiotics that soon cleared up her sinus infection.

Jason Gorevic, Teladoc's chief executive officer, says such encounters use familiar technology, "whether it's your cellphone, your laptop that has a webcam built in to it, or simply the phone."

In Texas, hundreds of employers offer Teledoc's services to more than 2 million employees, Gorevic said. Nationwide, Teladoc reaches 11 million people.

But new rules from the Texas Medical Board could make it a lot harder for people like Broyles to get antibiotics through the service. In response to the board's restrictions, Teladoc has filed a lawsuit that accuses the medical board of artificially limiting supply and increasing prices.

"The rules, as they're written today, only allow a physician who has seen a patient in person to interact with them remotely," Gorevic said. "That's basically saying you can't go shop anywhere else."

The rules do allow for certain exceptions that would permit a physician to diagnose or prescribe medications via phone or video. It would be OK, for example, if the patient were at a medical clinic, or another healthcare worker were with the patient and could do a sort of surrogate exam. There's also an exemption for remote mental health visits.

"How can a physician make an accurate diagnosis when they have no objective diagnostic data?" Robinson asked. "All they have is what the patient has told them."

And that's not enough information, she says.

"No one would think if they showed up at their doctor's office they would go back to a room, have the doctor stand on one side of the door, they would stand on the other, tell the doctor their symptoms and the doctor would slip a prescription under the door. No one would think that was good care," said Robinson. "That is exactly the same as doing it over a telephone."

But Dallas health care attorney Brenda Tso said that if you peek behind the curtain, the strict rules aren't just about patient safety.

"Doctors are trying to protect their practice from telemedicine, basically," she says.

Still, Tso said she thinks Teladoc's motivations are also financial.

The medical board is not suggesting that telemedicine should be completely stopped, Tso said. "That would be stupid. And nobody is saying that. Now, what the Texas Medical Board and the doctors are saying [is], 'Well, we should use it in a limited sense, as long as it doesn't affect the standard of care.' "

While the Texas Medical Board doesn't think it's good practice for patients to send photos, videos and text messages to unfamiliar doctors, attorney Rene Quashie points out that other states permit all those activities.

"If you look at states like Virginia, Maryland and New Mexico, they have laws and regulations that really facilitate the greater use of telemedicine," Quashie said. "Texas is not one of those states."

He noted that Texas has 200 counties that are considered medically underserved and more than a dozen counties that have just one primary care doctor. Those are places where telemedicine might have a larger role.

"There's a huge underinsured population in Texas," Quashie said. "Even people who have insurance sometimes have problems accessing care. So we're balancing access to care along with patient safety issues -- misdiagnosis and over-prescription. But we also want to allow companies to innovate in this space."

Access to doctors is the main reason insurer Blue Shield partnered with Teladoc in California. Executive Vice President Janet Widmann said at first telemedicine was meant to help rural members reach specialists. But it has grown beyond just the rural market.

"Now there's quite a bit of interest from our members in having the convenience of a telehealth visit. Folks want that," she said.

By next year 800,000 of the 3.5 million Blue Shield members will be able to use Teladoc in California.

In Texas, the medical board has already received more than 200 comments on the change of rules. It says key players, such as the Texas Medical Association, support the stringent rules. Teladoc points out, on the other hand, that the vast majority of the comments opposed the new rules. The new rules governing virtual visits were supposed to go into effect June 3, but have been delayed until the case goes to trial.

This article, which first appeared June 2, 2015, is part of a partnership that includesKERA, NPRand Kaiser Health News. Itwas reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

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